Mandatory In-Service for Non-Hospital Personnel
The purpose of this in-service is to orient you to the essential information that you are required to know
prior to starting your shadowing or clinical experience here at Indiana University Health Bedford
Hospital.
This packet must be completed in whole and returned to the Education Coordinator prior to beginning
any student or shadow experience. Contact information for the education coordinator is listed below:
Education Coordinator for IU Health Bedford Hospital:
Mrs. Melissa Mitchell MSN-E, RN, SANE-A
Office: (812)275-1303
Fax: (812)275-1341
Email: mmitchell3@iuhealth.org
IU Health Education Department Administrative Assistant
Mrs. Jennifer George can also be contacted in the absence of Melissa
Office: (812)275-1335
Email: jgeorge1@iuhealth.org
Packet Content Inclusion List:
Critical Access Hospital
ID Badges
Tobacco Free Campus
Patient Rights and Responsibilities
HIPAA & Confidentiality (PII, PHI, HIPAA Standards, Responsibility, Breaches, Social Networking)
Diversity & Appreciation of Differences
Abuse and/or Neglect
Quality Improvement
General Safety
Emergency Preparedness
Infection Control
Latex Allergy
Standards of Student Conduct
Alcohol-Free and Drug-Free Workplace
Harassment Prevention, Violence Prevention, Workplace Safety
Mandatory In-service for Non-Hospital Personnel
Page 1
Critical Access Hospital
Indiana University Health Bedford Hospital is a critical access hospital and has been deemed a “necessary
provider” by the state of Indiana. Critical access hospitals were created by the United States Congress in
the Balanced Budget Act of 1997 to support limited service hospitals located in rural areas. There are
certain eligibility requirements that must be met to qualify for critical access status.
Eligibility Requirements:
1. Can have no more than 25 acute inpatient or swing beds in the facility.
2. May have an unlimited number of observation patients.
3. Must be in a rural area.
4. Must maintain an average length of stay of 96 hours
5. Provide 24 hour emergency room services
6. Must be more than 35 miles from another hospital (A state provision was enacted to waive the distance
requirement for critical access hospitals that meet the state status as a “necessary provider”)
Benefits of being a critical access hospital
1. A higher rate of reimbursement for provided services
2. Current operations are maintained with little noticeable impact
3. Ensures community access to services
4. The flexibility to return to an acute care status at any time without interruption in service
ID Badges
Identification (ID) badges are to be worn at all times when on duty. This applies to all employees,
contract employees, and students. The ID badge is to be worn above the waist and in a manner that
allows the name and photo to be visible. No pins, stickers, etc. are to be attached to the badge. The
education department is responsible for taking photos for and producing the ID badges. The first lost
badge will be replaced for free and subsequent lost badges will charged a $5 replacement fee.
Tobacco Free Campus
Indiana University Health Bedford Hospital is a tobacco free campus. Our intent is to provide a safe and
healthy environment for our patients, visitors, and employees. To that end, tobacco use is prohibited in
all Hospital buildings, on all properties, grounds, and in company vehicles. This prohibition includes
walkways and surface parking lots. Students are to refrain from the use of tobacco during their shadow
or clinical shift (includes breaks and lunch) to avoid bringing the contaminants of tobacco that remain on
one‘s body and clothing into the care and work environment. These contaminants can trigger adverse
reactions in patients and colleagues similar to those caused by excessive perfume or other fragrances.
Should such contaminants create an issue management will intervene with education and coaching.
Further offenses will result in formal corrective action. Students are also expected to be respectful of
residences and businesses neighboring Indiana University Health Bedford Hospital.
Students who violate the Tobacco Free Campus Policy are subject to dismissal from the shadowing
or clinical program.
Mandatory In-service for Non-Hospital Personnel
Page 2
Patient’s Rights and Responsibilities (Found in the Patient & Visitor Guide)
Patients have the following rights and responsibilities:
1. Right to considerate and respectful care
2. Right to obtain information from the physician about his care, diagnosis, treatment and recovery
3. Right to receive information from physician to give informed consent prior to procedure and/or
treatment.
4. Right to feel secure and confident with services and care.
5. Right to feel secure and confident with services and care.
6. Right to be advised of any educational or research activities affecting his care or treatment, right to
refuse to participate.
7. Right to an explanation of hospital charges, and a Responsibility to make payment for services.
8. Responsibility to cooperate with hospital staff.
9. Responsibility to observe hospital rules and regulations.
HIPAA & Confidentiality: Health Insurance Portability and Accountability Act of 1996
Who does HIPAA Affect?
HIPAA is a regulation that affects the entire healthcare system for patients to employers, health plans,
physician offices, hospitals, dental offices, billing companies, healthcare clearinghouses and other entities
providing healthcare treatment.
What is the Scope of HIPAA?
HIPAA affects the Privacy and Security of protected health information (PHI) and personally identifiable
information (PII).
What is PII? (Personally Identifiable Information)
PII is electronic or paper information containing a person’s name, date of birth, address, social security
number, driver’s license number, photographic images, payment information or other private
information that one would generally want to protect from public disclosure.
What is PHI? (Protected Health Information)
PHI is individually identifiable health information transmitted or maintained in any form or medium,
which is held by IU Health or its business associates. PHI identifies the individual or offers a reasonable
basis for identification. Photographs within the context of patient care are PHI. PHI relates to past,
present or future physical or mental conditions, treatments and/or payments for healthcare.
HIPAA Standards
1. Transaction Standard:
*Applies to the electronic transmission of transactions outside of an organization or practice.
*The goal is to standardize the submission of claims for reimbursement.
*Benefit to practices: will increase the ability to electronically check patient insurance eligibility.
2. Security Standard:
*Applies to the security of an organization’s computer system and any information collected, obtained,
transmitted or stored electronically.
*Do Not give out your password.
Mandatory In-service for Non-Hospital Personnel
Page 3
3. Privacy Rule:
*Intended to protect or safeguard the privacy of protected health information.
*Protected health information is: Information that relates to the past, present, or future physical or
mental health or condition of an individual, the provision of healthcare to an individual; or the past,
present or future payment for the provision of healthcare to an individual.
*Areas related to the Privacy Rule:
-Notice of privacy practices
-Confidentiality of health information
-Ways to maintain confidentiality
-Faxing protected health information
-Accessing protected health information
-Obtaining consent
-Patient’s access to information
-Complaints
-Do Not access health information on self, family, friends, other staff or patients unless you are
caring for the patient or you have signed the release to see your own health information.
Who is responsible for following HIPPA standards?
Everyone has a role at IU Health to ensure information security, privacy, and integrity. Without your
engagement, sensitive information can be breached. Information breaches are not only costly to IU
Health, but individuals may also be held liable under federal and state statues as well as IU Health
sanctions. Ensuring the security, privacy, and integrity of patient and employee information is necessary
for IU Health to continue providing the community with high-quality care, innovation and service.
Ways to Prevent HIPPA violations.
1. Only discuss patient information with other healthcare providers that are directly involved in a
patients care.
2. Never discuss patient information in public areas such as: hallways, elevators, cafeteria, etc.
3. Always log-off or lock your computer if you are going away from your workstation or computer.
4. Keep computer screens turned away from public view or blocked as much as possible while in use.
5. Do not share your computer password with anyone.
6. If you need to fax sensitive information to another office or hospital. Double check the fax number,
always use an IU Health fax coversheet and call the other office or facility to tell them that you
have sent information.
7. Do no leave sensitive information on voicemail or answering machines.
8. Do not take pictures of patients without a healthcare purpose and only after a written consent has
been obtained.
9. Do not take any pictures with a personal camera or cell phone.
10. Do not post any pictures or information about patients on any internet forum or social networking
site (i.e. personal e-mail, Twitter, Facebook, MySpace, etc.)
Mandatory In-service for Non-Hospital Personnel
Page 4
11. Do not text any confidential patient information.
12. Dispose of confidential information in shred bins, if the bin is full or if you have a large amount to
dispose of call the number on the bin for pick up.
13. All electronic media must be physically destroyed or sanitized when being disposed of or
transferred to another use. Contact the IU Health Help Desk for assistance.
How do we handle breaches of confidentiality?
When there is a breach or potential breach of confidential information prompt action is critical. The
faster the breach or vulnerability is understood, the faster the response can be. IU Health is required to
submit to the U.S. Department of Health and Human Services any breaches of health information.
Breeches which affect under 500 patients may be submitted annually, breaches in excess of 500 must be
reported at the time of disclosure. We must report: date of the breach, date of discovery, number of
individuals affected, type of breach, type of information, and action taken. Whenever
you suspect a breach or potential breach of confidentiality notify your manager, Compliance Services, IU
Health Privacy Officer, or IT Security Officer immediately.
 Mr. Charles Shetler – CFO/Corporate Compliance, 275-1200 ext. 2610 cshetler@iuhealth.org
 Mr. Tim Brown – Privacy Officer/Corporate Compliance (812)353-9553 tbrown8@iuhealth.org
 Mrs. Tara Williams – IT Security Officer, 275-1200 ext. 2721 twilliams@iuhealth.org
Social Networking
IU Health Bedford Hospital workforce members and students have an ongoing obligation to protect the
privacy and confidentiality of our patients and patient’s family even when not at work. Employees and
students must adhere to IU Health Bedford Hospital’s policies and procedures related to privacy,
confidentiality, information security, and code of conduct. Do not post any confidential information or
protected health information on type of social networking site. It is inappropriate to discuss our patients
in any way on any social platform. Even if you don’t mention names or include specific information, this is
still inappropriate. IU Health Bedford Hospital/Physicians brand is best represented by its people and
everything you publish reflects upon it. Examples of social networking are sites such as Facebook,
Twitter, Tumblr, Instagram, Snapchat, etc.
Diversity
Diversity at IU Health Bedford is defined broadly to include group differences (based on age, race, gender,
sexual orientation, disabilities, parental status or job group, for instance) and individual differences,
including communication style, career experience, and other variables. Our goal is to create an
environment that is inclusive, drawing upon the strength of the diversity of our workforce to exceed the
expectations of IU Health Bedford’s customers. It’s about valuing the similarities and differences among
individuals.
Mandatory In-service for Non-Hospital Personnel
Page 5
What is Diversity not about?
• It is not about reducing standards.
• It is not about reducing our prejudices. It is about recognizing they exist and then questioning them
before we act.
• It is not a distraction from more important business issues. Like performance management, it is
standard by which IU Health Bedford performance is assessed.
• Diversity is not only black and white, female and male, Jew and Christian, young and old, etc.; but the
diversity of every individual, slow learner and fast learner, introvert and extrovert, controlling type and
people type, scholar and sports person, liberal and conservative, etc. Although it includes gender and
racial differences, it goes beyond that to touch on the very fabric that touches our everyday lives. Only
by accepting the uniqueness of others, rather than scorning them, will people want to help the team
succeed as a whole.
While at IU Health Bedford we can expect you to:
• Appreciate differences of peoples’ styles, cultures, gifts, and skills. Be willing to learn from others’
points of view.
• Be understanding – acknowledge that there can be differences between Western medicine and other
cultures’ health care values and practices.
• Be empathetic – be sensitive to the feeling of being different.
• Showing patience – understand the potential differences of concept of time and immediacy.
• Show respect – understand the importance of culture as a determinant of health; the existence of other
world views regarding health/illness; the adaptability and survival skills of our patients; the influence
of religious beliefs on health and the role of bilingual/bicultural staff.
• Be trustworthy – convey a commitment to safeguard our customers’ well-being.
Please remember that at all times, your behavior, attitude, appearance and general presence within this
physical location is a representation of IU Health. We take this representation very seriously as each
individual is a reflection upon our professionalism and our organization. If your behavior is
questionable, and/or does not reflect our quality of assurance standards that are expected of all
employees, your ability to continue within the shadow role may be terminated at any point in time.
Abuse and/or Neglect
Physicians, nurses, or any other hospital staff member shall report in accordance with state law (IC 3133-5-1) & (12-10-3) if they have reasonable cause to believe any person has been subjected to abuse
(physical injury, neglect, or emotional abuse). No one can be held liable for reporting potential abuse if
the report was made in good faith and the investigation does not reveal any wrongdoing.
If abuse or neglect is suspected with any patient, employees should contact Social Services at extension:
2526.
Mandatory In-service for Non-Hospital Personnel
Page 6
Suspected cases of child abuse or neglect can be reported directly to the Indiana Division of Family and
Children Services at 1-800-800-5556.
Remember abused victims can include all ages from children to the elderly; in any living situation no
matter how much money they make.
1. Types of Abuse or Neglect:
a. Physical Assault
b. Endangerment
c. Medical Neglect
d. Mental Torment
e. Rape or Other Sexual Assault
f. Abandonment
2. Indicators of Abuse/Neglect
a. An injury or illness that has not been cared for properly or repeated injury of the same type.
b. Body bruises or welts that cannot reasonably be explained
c. Dehydration and/or malnutrition without related illness
d. Decubitus
e. Skin burns
f. Signs of confinement
g. Overly frightened or disoriented
h. Explanations inconsistent with medical findings.
Suspected elder abuse or neglect can be reported to Social Services at ext. 2526 or directly to Adult
Protective Services at 812-883-5988.
Quality Improvement Activities
Kathy Lewis is the Director of Quality, Compliance and Risk Management and is also the patient safety
officer. She can be reached at ext. 1447.
The quality improvement process is organized and designed to support the values, mission, and vision of
IU Health Bedford Hospital. The leadership is dedicated to the philosophy of continuous performance
improvement throughout all levels of the organization.
1.
2.
Performance Improvement Proposal – any idea that anyone may have to improve a process or
make care for our patients better may be presented to the Director of Quality. The ideas may be
verbal, by phone, by e-mail or on an official Performance Improvement Proposal Form.
Organizational Teams – an interdisciplinary team of employees set up to work on Performance
Improvement.
Mandatory In-service for Non-Hospital Personnel
Page 7
Goals of Quality Improvement:
1. To develop and support an environment where every staff member’s capability is improved.
2. To create an environment where innovation and creativity are encouraged.
3. To foster a patient focused ethic where the needs and expectations of our customers are met or
exceeded.
4. To encourage an interdisciplinary /collaborative approach to the delivery of care or service with
the focus on the patient.
5. To reduce duplication efforts, effectively coordinate and maximize quality improvement activities.
6. To establish effective quality improvement management systems with the purpose of integrating
the knowledge and expertise of quality improvement, risk management, infection control,
corporate compliance, credentialing, monitoring activities and utilization management.
General Safety
1. Electrical
 Never use an adapter if the grounding pin has been removed.
 Do not use extension cords unless specifically approved by engineering.
 Always unplug electrical devices by firmly pulling the PLUG, not the cord.
 If you receive even a small amount of shock from a device, report it immediately and take the
device out of service.
 Report any hazardous condition or unauthorized device.
 Do not bring any electrical equipment to work, if you do it must be checked by engineering.
2. SDS: Safety Data Sheets (Previously known as MSDS Sheets, or Material Safety Data Sheets)
SDS sheets are a universal method to provide data and information about chemicals that you may use
during the performance of you job duties.
The information contained in an SDS sheet is now divided into specific categories for labeling and ease of
label reading.
This information includes:
Section 1: Identification
Section 2: Hazard(s) Identification
Section 3: Composition/Information on Ingredients
Section 4: First-Aid Measures
Section 5: Fire-Fighting Measures
Section 6: Accidental Release Measures
Section 7: Handling and Storage
Section 8: Exposure Controls/Personal Protection
Section 9: Physical and Chemical Properties
Section 10: Stability and Reactivity
Mandatory In-service for Non-Hospital Personnel
Page 8
Section 11:
Section 12:
Section 13:
Section 14:
Section 15:
Section 16:
Toxicological Information
Ecological Information (non-mandatory)
Disposal Considerations (non-mandatory)
Transport Information (non-mandatory)
Regulatory Information (non-mandatory)
Other Information
 OSHA states that organizations provide information to employees, volunteers, and students on
items that they are exposed to that may do them harm.
 If an employee, volunteer or student cannot tell OSHA inspectors where MSDS Sheets are located it
is an immediate fine $$$$
 MSDS information is available anytime by using the number below.
For assistance, contact us. We can help. It's confidential
U.S. Department of Labor
www.osha.gov (800) 321 OSHA (6742)
3. Fire Safety
Fire Drills are performed every month in a different location, and at different times as part of a training
program/regimen to keep staff and students current and up to date with fire procedures.
 A hospital representative will present you with a sign the says “FIRE”
 Dial 199 (IU Health Bedford operator’s direct line)
 State, “Fire Alert, the unit where you are/ where the fire is located, and your Name”
 Listen for “Fire Alert” to be announced. The operator will announce this information 3 times.
 Pull the Fire Alarm
 Shut all doors, turn off air handlers (if it is your assigned duty) and electrical equipment except
lights.
 If the fire drill is not on your floor:
 The fire extinguisher from your areas should be taken to the area where the fire is located
to help fight the fire.
 The fire extinguisher is taken by the person who’s assigned to the duty according to the
Fire Safety Manual located in your area.
REMEMBER that in a true fire situation:
Phone the operator at X199 and Activate the “Fire Alert”
Report where the fire is located & state your name.
The operator will announce 3 times so that all staff have opportunity to hear it overhead.
The RACE Procedure should begin immediately.
Mandatory In-service for Non-Hospital Personnel
Page 9
The acronym RACE stands for:
R = Remove anyone in danger.
A = Activate the system, dial 199 (BRMC0 or 911.
C = Confine the fire; close the doors, and windows.
E = Extinguish the fire (if it is safe to do so).
Use a fire extinguisher to contain and put out the fire. Staff members from other areas will respond and
will bring extinguisher reinforcement with them.
The acronym PASS stands for:
P = Pull the locking pin
A = Aim the nozzle at the base of the fire.
S = Squeeze the handle
S = Sweep using side to side motion (8-10 foot sweep, aim nozzle at the base of the fire).
PLAIN LANGUAGE USE, INSTEAD OF CODED LANGUAGE
In an effort to remove the guess work of deciphering what code numbers and terms are when announced
overhead, IU Health as a system is becoming more transparent in 2015 and we are implementing plain
language announcement of emergency events. The following description of events represents the
verbiage used in relaying this information to staff, students, and visitors. This is the chart that was
provided to all staff in March of 2015 when plain language went live in IU Hospitals across the state.
Type of Emergency
Fire
Medical Alert Repiratory or
Cardiac Arrest
Medical Alert Rapid Response
Medical Alert STEMI
Medical Alert Stroke
Abduction
Elopement
Severe Weather
Behavior Alert
Active Threat
“Plain Language” Announcement (what you will hear overhead)
Fire Alert - Fire alarm activated (building, floor, department). Staff
(and students) are to Follow RACE procedures.
Medical Alert - (floor, department, room #). Resuscitation team
required.
Medical Alert - (floor, department, room #). Code Yellow response
required.
Medical Alert - (floor, department, room #). Code Yellow STEMI
response required.
Medical Alert - (floor, department, room #). Code Yellow Stroke
response required.
Abduction Alert - Missing infant/child (floor, department, room #).
Description (age, gender, clothing, hair color, ethnicity). If located,
please contact the operator or House Supervisor.
Elopement Alert - Missing adult (floor, department, room #).
Description (age, gender, clothing, hair color, ethnicity). If located,
please contact the operator or House Supervisor.
The National Weather Service has issued a (description) for (county
name). The watch/warning is in effect until (time). Please move to
an interior corridor away from windows.
Behavior Alert - (floor, department, room #)
Security Alert - active threat, (department/location).
Mandatory In-service for Non-Hospital Personnel
Page 10
Active Shooter
Restricted Access
Internal Disaster
Internal Disaster
External Disaster
External Disaster
Security Alert - There is an active shooter in (department/location).
We are going into restricted access mode until this situation is under
control by local law enforcement. Please locate a safe place and stay
there until an all clear is announced.
Security Alert - We are going into restricted access mode.
Internal Disaster Alert, Level (1, 2), (description) has been activated.
Internal Disaster Alert, Level (3, 4), (description) has been activated.
All departments please complete a Status Report Form and submit it
to the Hospital Command Center.
External Disaster Alert, Level (1, 2), (description) has been activated.
External Disaster Alert, Level (3, 4), (description) has been activated.
All departments please complete a Status Report Form and submit it
to the Hospital Command Center.
Infection Control
The infection control nurse for IU Health Bedford is Teresa Mathis and she can be reached at ext. 2650.
Universal Precautions
• Treat all blood and other body fluids as if they are infected
• Hand washing before and after contact
• Personal Protective Equipment – Gown, gloves, and masks when performing any procedure that is
likely to cause splashes, spray or splatters of blood or body fluids. Never take contaminated PPE or
clothing home for laundering.
• Sharps – Never bend, break or recap contaminated needles. Dispose of all needles in the sharps
containers (red).
• Laundry - Soiled laundry is never separated. Place all laundry in soiled laundry hampers. Use standard
precautions when handling all soiled laundry.
Exposure to Blood/Body Fluids
• Perform wound care and/or flushing of exposed area.
• Report to Occupational Health during the hours of 8am and 5pm, Monday through Friday.
• Report to ER as soon as possible within 2 hours of post exposure prophylaxis (PEP) to HIV and hepatitis
B if indicated after 5pm Monday through Friday and on the weekends.
• Notify the House Supervisor.
• Complete the following: o Employee Exposure Report
o Authorization for Release of Information
o Reporting Procedure for Employees
• Initial exam and management post exposure will be done in ER. Counseling should be sought if not
given in the ER. Further follow-up will be done by the Infection Control Nurse.
Mandatory In-service for Non-Hospital Personnel
Page 11
Transmission Based Precautions
Transmission-based precautions are used in addition to standard precautions for patients who have, or
may have, a contagious disease. These are divided into 3 types: airborne, droplet, and contact.
• Airborne precautions – Prevents the spread of infectious dust particles or small particle droplets that
remain in the air. Airborne precautions require the use of a mask, special air handling and ventilation.
Workers/Caregivers must wear an approved mask when entering the room of a patient with TB.
• Droplet precautions – Prevents the spread of infectious large particle droplets that can be created by
certain medical procedures, or by coughing, talking, sneezing. Care of the patient on droplet prcautions
requires the worker/caregiver to use a mask and goggles.
• Contact Precautions – Prevents the spread of an infectious disease by skin-to-skin contact or by contact
with a contaminated object. Workers/caregivers are required to use gloves, gown (possibly goggles
and/or mask).
Isolation Precautions
Isolation precautions protect against the spread of infection.
• Signs on the door of the patient room will indicate the type of precautions and what PPE is required.
Examples would be – contact, droplet, airborne, etc.
• The proper PPE will be available outside the room.
• Containers for linens and biohazard waste will also be available.
Waste Segregation
 Sharps Containers: needles, syringes, IVs, scalpels, blades, suture, broken glass
 Red Bags: IV bags, IV tubing (if visible blood), human blood and blood products, amniotic fluid,
semen, human pathological waste.
 General Waste: glove boxes, coffee cups, personal protective equipment (no visible body fluids)
Latex Allergy
What is Latex?
Latex is the milky fluid derived from the rubber tree. It is used to make natural rubber. Synthetic rubber
is also referred to as latex, but synthetic rubber does not release the proteins that cause allergic
reactions. Latex is used to make thousands of products that we use every day. Latex gloves have proved
effective in preventing transmission of many infectious diseases to healthcare workers.
Note: Latex balloons are no longer allowed in hospital care settings due to the incidence and uprise of
known latex sensitivity and latex allergy. Mylar balloons are acceptable.
IU Health as a system has made a serious effort to minimize the use of any/all latex products within the
hospital product line in a further effort to prevent reaction/exposure to staff, students, visitors, and
Mandatory In-service for Non-Hospital Personnel
Page 12
patients alike. Products such as gloves, catheters, tourniquets and other such items are now available in
latex free forms.
• Latex Allergy
 Immediate hypersensitivity reaction caused by certain proteins in latex.
 Latex allergy can occur from repeated skin contact or inhalation of latex proteins.
 Repeated exposures to natural and synthetic latex can result in a latex allergy.
 Powdered latex gloves create a much higher risk for latex allergy than powder-free latex
gloves.
 Hypoallergenic latex gloves do not eliminate your risk of allergic reactions to latex
exposure.
 Symptoms range from mild to severe and may include: runny nose, itching eyes, scratchy
throat, asthma like responses, and possible collapse of airway
Reactions can occur within minutes or hours of the latex exposure. Work areas where only powder-free
gloves are used have very low levels or undetectable amounts of allergy causing proteins.
Risk & Treatment of Latex Allergy
 Who is at risk of developing latex allergy?
 Healthcare workers who frequently use products containing latex
 Person with multiple allergic conditions
 Treatment of latex allergy
 Prevention
 Avoidance
 Treatment of symptoms
Student Standards of Conduct
You are an ambassador to the hospital and our reputation in the hospital and the larger community
depends upon the behavior of our ambassadors. You are expected to conduct yourself in a mature,
dignified and honorable manner at all times.
Inappropriate conduct will not be tolerated and may result in your termination from the program.
Inappropriate conduct includes, but is not limited to:
1. Dishonesty, including but not limited to cheating, lying, falsification of records, and theft.
2. Insubordination, including refusal to perform work in the manner, time, or place assigned.
3. Illegal sale or illegal use of controlled substances on hospital property.
4. Use of intoxicating substances on hospital property, or reporting for orientation, training or
clinical experience in an intoxicated condition.
5. Negligence which endangers or injures patients, visitors, and students, or staff.
6. Conduct which creates a disturbance or could have a detrimental effect on patient care or the
learning environment.
Mandatory In-service for Non-Hospital Personnel
Page 13
7.
8.
9.
10.
11.
Violation of hospital policy regarding gambling or use of firearms or other weapons.
Violation of the confidentiality of patient information.
Use of inappropriate language.
Conviction of a felony while participating in the program.
Performing unauthorized procedures.
Alcohol and Drug-Free Workplace
It is policy to maintain an alcohol and drug-free workplace to provide a safe and healthy environment for
employees, patients, families and guests; to reduce the incidence of accidental injury to person or
property; to reduce absenteeism, tardiness and poor or indifferent job performance; to ensure the
positive reputation of IU Health Bedford Hospital’s policy.
Staff members who have reason to believe that a student’s performance problems or poor attendance is
being caused by off-duty alcohol or controlled substance use will be referred to your School Program
Coordinator.
Any student using drugs or controlled substances is subject to disciplinary action, including
termination from the program
Drug screening will be completed prior to the beginning of each student experience.
Harassment and Workplace Violence Prevention
IU Health Bedford Hospital is committed to maintaining a culture that provides a safe and healthy
environment for students, employees, patients and visitors. We do not condone or permit threats,
harassment, or violence. A zero-tolerance approach for violence of any kind is maintained. We are
committed to a supportive environment and will act expediently in addressing behavior that is
considered threatening, harassing or violent in nature.
“Threatening behavior” is defined as an expressed or implied threat that endangers or could interfere
with an individual’s health, safety, and/or property or with the property of IU Health Bedford Hospital,
which causes a reasonable apprehension that harm is about to occur.
Harassment refers to behaviors that are offensive and fail to respect the rights of others. Harassment can
be verbal or non-verbal conduct designed to intimidate or coerce.
Violent behavior is the use of physical force or violence that restricts the freedom of action or movement
of another person, or endangers the health or safety of another person, or the property of IU Health
Bedford Hospital.
Any student who believes that he/she is being harassed, threatened, or subjected to violent behavior
should report the alleged action immediately to his/her Department Head or School Program.
Mandatory In-service for Non-Hospital Personnel
Page 14
Coordinator. If the action involves the Department Head or School Program Coordinator, the student
should report the alleged action to the next level of management.
A timely confidential investigation of a compliant will normally include talking with the parties involved
and any named or apparent witnesses. All students shall be protected from coercion, intimidation,
retaliation, interference or discrimination for filing a complaint or assisting in an investigation.
If the investigation reveals that behaviors have occurred as outlined in this policy, prompt attention and
disciplinary action will be taken to stop the behavior immediately and to prevent any recurrence. If the
investigation reveals that a student is the source of the harassment or threatening behavior, the student
will be dismissed from the student shadowing or clinical program.
Sexual Harassment
It is the policy of IU Bedford Hospital to ensure an environment free from sexual harassment. The facility
does not condone or permit behavior, which is construed as sexual harassment.
Sexual harassment includes, but is not limited to, unwelcome sexual advances, requests for sexual favors,
and other verbal or physical conduct of a sexual nature or other displays of harassment.
Sexual harassment does not refer to behavior of occasional compliments of a socially acceptable nature. It
refers to behaviors that are not welcome, personally offensive, fail to respect the rights of others, lowers
morale and interferes with work effectiveness.
Any student who believes that he/she has been the subject of sexual harassment should report the
alleged act immediately to your Department Head, or School Program Coordinator. If the complaint
involves your Department Head, the student should report his/her complaint to the Human Resource
director at the hospital.
Timely and confidential investigation of a complaint will normally include talking with the parties
involved and any named or apparent witness. All students shall be protected for coercion, intimidation,
retaliation, interference or discrimination for filing a complaint or assisting in an investigation.
If the investigation reveals that harassment has occurred, prompt attention and disciplinary action will
be taken to stop the behavior immediately and to prevent recurrence. If the investigation reveals that a
student is the source of the harassment, the student will be dismissed from the shadowing or clinical
program.
Mandatory In-service for Non-Hospital Personnel
Page 15